Wiki E/M w 25 Mod denied on first visit

[crispenn]

I have a denial for an E/M with 25 modifier for an injection on the patients first visit with the provider. Can you please point me the direction or show me how I can best appeal this? The patient has been seen by another provider in our practice but for a different body part.

 

[Orthocoderpgu]

The CMS general coding guidelines specifically states that just because a patient is new does not mean that an E/M is justified. The injection has a built in "E/M". Probably why it was denied.

 

[nraizman@gmail.com]

It all comes down to documentation.
The E&M associated with an injection or minor procedure only encompasses a brief discussion of the risks, benefits, alternatives and expected results and post-procedure management. It does NOT encompass the evaluation of the patient.

If your doc did not document the evaluation that led to the diagnosis of the condition and the discussion of potential treatment options etc, and if they don't make it abundantly clear it is a separate and identifiable E&M service, then they won't have a leg to stand on.

CMS supports the reimbursement of the E&M with appropriate use of -25. It is in the NCCI Policy Manual.
You might want to use the text of the NCCI Policy Manual in your appeal.